Chapter Five - Vasectomy: The Unkindest Cut of All

The idea that vasectomy could be a major cause of the andropause makes the many doctors who recommend it, and those who inflict it on unsuspecting patients rush to its defence, with faith, but usually little detailed knowledge of the many possible adverse reactions to it.  Since it first came into fashion over thirty years ago, this seemingly trivial operation has variously been described as "The most loving thing that a man can do for a woman", to "The unkindest cut of all" - a “Surgical Sword of Damocles” threatening the testes.

It's been carried out in men for just over a hundred years now, and the operation is still surrounded by controversy.  The first human vasectomy was performed in 1894 by a British surgeon to reduce the size of an enlarged prostate, which it apparently failed to do.

However, the operation never became widespread till in 1916 a Vienese surgeon, Ludvig Steinach, proclaimed it was a method of rejuvenating the male.  His theory was that if the part of the testicular factory manufacturing sperm was shut down, it would leave more room for the testosterone producing cells to flourish, which would reduce ageing.  The idea proved popular, and on the basis of many reports from patients who claimed the operations had done wonders for them, thousands of men were "Steinachered".  There were even reports that the illustrious father of psychoanalysis, Sigmund Freud, who also lived in Vienna underwent the operation to promote longevity and revive his sexual powers, but perhaps this was just to overcome a psychological block.

It was also from 1909 onwards, used as a tool in social engineering, to limit reproduction by any people considered as "defective individuals".  A particular enthusiast for this for of eugenics was a Dr Harry Sharp, resident physician at the Jeffersonville Reformatory Indiana.  He compulsorily vasectomised two hundred and eighty men because they had defects of character such as "selfishness, ingratitude, inconstancy, egotism, and inability to resist any impulse or desire'. or masturbated excessively.  While these traits must obviously have been very rare in the population in those days, at least in Indiana, a considerable number might now be considered as elligible for this procedure on these grounds in most countries.

People on whom this form of involuntary sterilisation could be inflicted ranged from colour‑blind individuals to those offspring it wished to limit because of their colour or creed.  From 1933 onwards, under the law 'Prevention of Hereditary Disease in Posterity" the German Government forced over a million men it considered unfit, including probably not coincidentally a large proportion of Jewish people, to undergo vasectomy.

In the United States in 1922 thirty‑one states had statutes permitting involuntary sterilisation of "defective individuals".  Even with the outcry over its abuses by the Nazis, twenty‑one states retained these laws after the second World War, and as recently as 1973 Tennessee, Mississippi, Ohio and Illinois introduced bills ordering the sterilisation of those on welfare with two or more children.  California and Oklahoma made vasectomy a condition of suspending prison sentences in those convicted of robbery or not supporting their families, whereas the Child Support Agency in Britain seem to prefer financial castration.

In India it has been vigorously promoted as a part of government population policy.  A new World record was achieved in 1971 by holding a "Vasectomy Camp" which sterilised 63,000 men in one month, with 100 surgeons working non‑stop round the clock, and a variety of circus side shows to entertain those waiting their turn.  Three years later it was revealed that gangs of "motivators" who had been offered small sums to encourage men to undergo the operation had misled or forcibly press‑ganged or blackmailed men to undergo the operation, and nearly half wished they had never had it done.

In Britain in 1994 an alarming increase in vasectomy rates in men in their early twenties was thought to be due to the recession and job losses making it difficult to afford the cost of housing a family. One wonders how many of these men will regret the decision that was forced on them at such an early age.

Despite this chequered history, vasectomy really took off as a means of contraception from the 1960's onwards, and it has been estimated that currently 500, 000 Americans, 20, 000 British, and 10,000 Irish have the operation each year.

My first experience of the clinical effects of vasectomy was in 1979 when I first visited the clinic of Dr. Jens Moller in Copenhagen, one of the "Heroes of the Hormonal Revolution" as described in the first chapter.  A surprising number of his patients who nearly all were being treated with testosterone for severe problems with the circulation in their legs, often with heart disease as well,  had had a vasectomy many years previously.  When I commented on this Dr. Moller simply said "Ah yes.  When I hear a patient has had a vasectomy, I know he is a case for me!".  This seemed at the time to be a rather extreme remark to make, but it prompted me to look up the literature on the subject.

Rather to my surprise, because it was such a commonly accepted operation which I had only just escaped having myself in the nick of time so to speak, I found that there was a considerable amount of evidence to support Dr. Moller's view that it might have harmful effects on the heart and circulation in some patients.

For over thirty years the operation had been sold to the unsuspecting public, as it still is, as a snip, which stands for Simply No Immediate Problems.  Unlike any other operation however minor, no general medical examination is done beforehand, no central records are kept of how many operations have been performed, and counselling is limited to the fact that it is irreversible so be sure you want it done.  Any questions about "What happens to the sperm?" are brushed aside with facile answers such as "They are just absorbed ‑ its quite safe really".

Let's look first at what happens during and after the operation, and then at what can and does go wrong.  It is a deceptively simple 'minor' operation which can be, and often is, carried out by the most junior and inexperienced of surgeons.  It takes quarter to half an hour and so lends itself to mass application in clinics set up for the purpose on a conveyor belt system, with a surgeon running from cubicle to cubicle trying to set a new lap record for what is a seemingly simple repetitive task.

The actual procedure is carried out under local anaesthetic, and through a small incision the tube carrying the sperm from the testis on each side to the prostate gland below the bladder, the vas deferens which gives the operation its name, is exposed.  It is then dissected free of the fine nerves and blood vessels which run alongside it in the spermatic cord, and sealed off.  This may be done by cutting it and tying off one or both ends, by frying it with electrocautery, or by blocking it with a plastic spigot which is claimed to be more easily reversible.

To the patient and surgeon alike it is seen as a simple plumbing job to turn off the stop‑cocks and prevent sperm getting out of the testes.  It is presented as a cheap and effective form of contraception, for which one is awarded a portable radio for an act of social conscience in India, and a tie inscribed IOFB, standing for "I Only Fire Blanks" in Britain.  As the anti‑vasection lobby gathers strength, refusenick member may well come to sport ties inscribed IOFLA, standing for "I Only Fire Live Ammunition".

A drug, such as testosterone, has to have in the packaging a formidable list of every complication, however rare, ever recorded in association with the use of that compound, and often for good measure every related compound.  Not surprisingly, unless reassured how very infrequent these are, and whether or not they have been reported with that particular compound, patients cannot make an informed decision about whether to take the prescription.

The same should apply when an operation such as vasectomy is prescribed, but the possible complications discussed here are rarely mentioned, and certainly not covered in the detail deserved by such an important topic, which may affect the man for literally the rest of his life.  Vasectomy is after all a major surgical insult to a very sensitive, delicate and highly tuned organ.

The vas is just one of the structures in the spermatic cord which may be damaged by the operation and the bruising, infection and scarring which can follow.  Running alongside it in the cord is a sheath of fine blood vessels, nerves and lymph vessels which nourish the testis, control its temperature to within very critical limits, and drain fluid away from it.

Temperature control of the testis has been showed to be impaired after vasectomy, as has the drainage of fluid from around it so, that collections of fluid called hydrocele are formed in many cases. This "water‑jacketing" tends to raise its temperature which can have a harmful effect on the testes ability to produce both sperm and testosterone.  Also, there are nerve connections between the two testes, and damage to one can affect the other in a variety of ways.

After the operation there may be a variety of other complications, which can be divided into short and long term.  There is often mild to moderate discomfort which may cause the patient to be off work for anything from an hour to a week, depending on his pain threshold, motivation and how many of the fine nerve endings that run alongside the vas get caught up in the operation.

Fortunately quite infrequently, a variety of other changes can occur which cause a persistent and disabling "post‑vasectomy pain syndrome". These seem to be associated with the development of small lumps in the scrotum due to overgrowth of the trapped nerve fibres, called neurones, or swellings at the severed ends of the vas due to a local tissue reaction to sperm, called granulomas. These have been estimated to occur in up to 90% of cases but are usually small and pain‑free.  They may however increase the chances of antibodies against the patients own sperm. Also there may be scarring of the testis from the bruising, and damming‑back of the sperm and other products of the testis which now have nowhere to go into small swellings of the vas, called cysts.

You only have to meet a few of these post‑vasectomy cripples to be far more cautious about recommending the operation.  One of these cases is Harry:

"I had my vasectomy 10 years ago now and I havn't had a happy, pain‑free day since.  Its been a nightmare from beginning to end, and its not over yet.

After seven years on the pill, my wife was advised to stop taking it, and so I decided I'd have a vasectomy.  On the day of the operation at our local hospital I had no second thoughts at all because I had heard that the procedure was quite straightforward.  I was surprised therefore to wake from the general anaesthetic with a tremendous pain in my stomach. The nurse reassured me the pain would go away and gave me a valium.  But when my friend arrived to take me home an hour later, I was still bent double with pain.

After a couple of days with no respite, I called in my own doctor who confirmed that it would settle down.  But for the next few weeks I was only comfortable when I was lying down.  Walking or lifting things was impossible and there was no question of being able to work. I was getting increasingly anxious as I had never really been ill before, but since both the hospital and my doctor were adamant there was nothing to worry about, I was prepared to give it time.

Then two months after the operation I found two small and painful lumps in each testicle.  I was told these were sperm granulomas, the sperm not being properly absorbed into the body, and was shocked when the consultant told me he wasn't  experienced in dealing with such problems and wanted to refer me to another hospital.  By the time this appointment came up, the lumps had grown from being the size of match heads to the size of peas and they, together with the continuing ache in my stomach region, were causing me such discomfort  that it was interfering with my sex life.

The new consultant performed an operation to remove the lumps.  Afterwards he told me he believed too much of the had been cut during the vasectomy which explained the painful pulling sensation in my stomach.  I was very angry.  The lumps kept recurring and this was complicated by bouts of urinary infection that caused a painful inflammation in both testicles.  To help this the surgeon finally had to remove the inflamed outer casing of the left testicle, the epididymis.  Even this went wrong, and five months later the testis on that side began to shrink, and I had to have it removed and a plastic prosthesis put in.

By now I felt extremely low and tired and couldn't understand why.  Some tests done down in London showed a very low testosterone level and that I was so allergic to my own sperm that even when they diluted my blood more than 2,000 times they could still get an antisperm reaction.

I was started on some tablets called Proviron and these made me feel slightly better,  but it took testosterone injections to make me feel much fitter, but even these wore off after a time.  Last year I had to have the same series of operations on my right testicle, with removal of a granuloma, and then the epididymis, and now the testicle gets inflamed and is shrinking, so I may have to have even that removed.

Its been such a terrible time since the first operation.  My job as a fork‑lift truck driver which I'd had for eighteen years before the vasectomy is gone ,and my wife left me because it all got too much and we weren't having any fun or any sex.  There have been times over the last few years when the pain and worry have made me think of ending it all, but things are slightly better now.

All this has been a result of a vasectomy gone wrong, probably because it was performed in a hurry by someone inexperienced, though I'm told it sometimes happens in the best of hands. This surgery sentenced me to ten years pain and misery".

Long term complications of vasectomy may be much more common and diverse than is generally recognised.  Of the limited amount of research which has been done, some is reassuring and some rather worrying.

"What happens to the dammed‑back products of the testis?" you may well ask.  If both ends of the vas have been tied off, the pressure in the stump attached to the testis builds up, and sometimes cysts form in the sperm collecting tubules surrounding the testis, which can be felt as small lumps.  Sometimes the cysts in the epididymis burst open and granulomas arise.  If the vas has been left open, then the sperm spill out into the loose tissue in the scrotum, and granulomas are then more likely to form than cysts.

In either case, but particularly where granulomas have formed, the body reacts to this highly unnatural no‑exit situation by becoming allergic to its own sperm, and producing anti‑sperm antibodies.  This is because sperm are only produced after puberty and are normally kept shielded from the body's immune system which would otherwise attack them and form antibodies, reacting as it would to other "alien" proteins such as those produced by bacteria and viruses. Vasectomy spills sperm into the tissues around the testis, and exposes them to the antibody producing cells.

Antisperm antibodies are found in up to three-quarters of vasectomised men, as has been widely recognised and accepted for many years.  One medical textbook on the subject cheerfully says "Vasectomy can be considered a particular form of experimental autoimmunisation".  Some of my patients reported a prolonged and debilitating flu‑like illness within the first few months after vasectomy, which is when immune reactions would be expected, and granulomas appear.

But apart from causing infertility problems in patients wanting the vasectomy reversed, which happens in 1% of men, no‑one seems to have thought through the other likely consequences.  Its like tying a knot in the barrel of a rifle, and being surprised when it blows back in your face!  With this in mind, I have been carrying out detailed antibody profiles in the post-vasectomy patients who have come to see me.  There are some interesting but inconsistent findings which I am now analysing in detail.

Some patients show an active generalised immune process as shown by raised levels in the blood of a protein called "Immune complement" which has been linked to the possibility of increased heart and circulatory disease after vasectomy.  The majority show anti‑sperm antibodies as would be expected.  An interesting and as far I know unexplained sex difference is apparent here.  When women develop antisperm antibodies, these usually cause the sperm to clump together "Head-to-Head", whereas the majority of my post-vasectomy men seem to have "Tail to Tail" antibodies, sometimes active when their plasma is diluted over 16,000 times.  Logic suggests that if you have antibodies against sperm, you might well develop antibodies against sperm‑producing cells in the testis, the Sertoli or nurse cells, and indeed this is found in a proportion of cases.

What was not expected was the finding in other cases of antibodies against the testosterone producing, interstitial cells, though this again seems logical.  The sperm and testosterone producing cells work together, literally side by side, on the common mission of producing and launching these "Egg‑seeking Missiles".  Recent research has shown just how closely these functions are linked in many ways, including their own hormonal communications, the so‑called paracrine actions.  If you suddenly shut down one half of the factory, common sense would indicate that you might have some effects on the other.  Testicular biopsies from vasectomised men have shown just such changes, and from my research and that of others there is evidence that this is indeed the case.

Vasectomy and the Andropause

Over the last ten years, I have been impressed by the fact that just over 200 out of the thousand men in my practice complaining of symptoms of the andropause have had vasectomies, usually 10‑15 years previously.

It is difficult to get accurate reports on the proportion of men in different countries who have had vasectomies because the operation is assumed safe and thought too trivial to be worth recording.  However, as the best estimate of the frequency of vasectomy in the general population of this age and social group is around 10%, there seems to be a significantly higher proportion of men who have had this operation in the andropausal group.  Not only are these patients on average 5 years younger than the rest, but often this operation appears to be the only risk factor present.

The most common time for the symptoms to appear is ten to fifteen years after the vasectomy.  This time scale was confirmed independently by another group in London, who also showed a fall in testosterone levels at this time. Other studies from Egypt and Belgium have shown that the amount of testosterone and one of its active fractions dihydrotestosterone (DHT) in the ejaculate are reduced to one third by vasectomy.

Most of the studies of the effects of vasectomy on hormone production are relatively short‑term, being over three to five years at most.  Almost all were carried out ten to twenty years ago, before vital factors such as Sex Hormone Binding Globulin (SHBG) and Prostate Specific Antigen (PSA) were being included in even research studies.

It's true they excluded any dramatic drop in total testosterone levels in the first five years after vasectomy, and some even showed an increase in one of its active fractions, dihydrotestosterone (DHT) and one of the pituitary gland hormones which promotes the production of both,  Follicle Stimulating Hormone (FSH).  However this indicates at least some hormonal changes occur even in this relatively short time scale, which could be taken to show some disturbance in testicular function, if not actual damage to its structure  Rather than vasectomy making you sexier as suggested by one study recently, since DHT is not the primary hormone governing libido, a more likely explanation is that the pituitary gland is trying to compensate for impaired testosterone production by spurring the testis to greater activity, and increasing its turnover rate.

The surge in these two hormones could also explain why there have been several reports of an increased number of cases of testicular cancer within the first four years after vasectomy, reaching a maximum after two, though there are other studies which contradict this. The tumour, which is increasing at a rate of about two percent per annum, particularly in young men, is most common when the testicles fail to descend, which is a condition also associated with raised FSH's.  It has recently been linked to environmental oestrogens, which may have a similar effect in contributing to testicular failure and high FSH levels.  It is fortunate that this is one form of cancer where great advances have been made in treatment.

Another form of cancer which has been linked to vasectomy in some studies but not in others is that of the prostate.  Evidence is particularly conflicting here but again if it is proven could be explained by long term hormonal disturbances..  Reduced semen flow through the prostate has been suggested as another possible link, but seems unlikely as vasectomy only reduces semen volume by 5%, and this form of cancer is not particularly common in men leading a celibate life such as monks.

Typical of the menopausal men I have seen where vasectomy seemed to be the most likely cause of the problems is the 49 year old dentist Tom.

"I had my vasectomy 10 years ago, it was very painful and I had a lot of bruising.  Suddenly, for no apparent reason, 5 years ago the bottom dropped out of my sex life.  I used to be quite a flirt but then the sexual chemistry went. and totally unlike me, sex never entered my head..  About the same time, quite suddenly my morning erections disappeared, and soon the evening ones went out of the door with them especially when I wanted them most.  This made me so worried that a bit like my golfing swing, which worsened at the same time, I got paralysis by analysis.

Also, while I used to really fizz all the time, I became a real slouch, stopped going to parties, and started feeling old before my time.  Then the circulation in my fingers and toes got quite bad even in the mild weather, and my feet started going numb.  Even my joints started seizing up and got very stiff first thing in the morning and after golf or going running, both of which I used to enjoy, but turned into a real bore and chore with all these symptoms.

At this stage I went and had a thorough check‑up by my andrologist, who showed that the free testosterone in my blood was very much reduced.  Capsules of testosterone by mouth gave a lot of improvement, but it wasn't until I started on the pellet implants into the buttock that the symptoms really went away and I got back to my old sexy self.

Best of all my golf improved enormously, my handicap which had deteriorated badly over the previous four years, went down by about five, and I started to beat the club champion and do well in away matches.  The main difference was in my swing which had become hasty and snatched, but on testosterone is really flowed.  Other people noticed the difference , especially my coach, and asked what I was on, but I havn't told them.  I don't think it's my imagination either because every five or six months when my implant is running down, my golf gets worse, as does my temper and sex life, and they are only restored by another shot of testosterone".

Especially when there are other causes of testicular failure such as alcohol or mumps, vasectomy definitely seems to lower the age at which menopausal symptoms appear.

Vasectomy, the Heart, and Circulatory Disease.

A great deal of work has been done on the possible link between vasectomy and heart and circulatory disease, and I find the evidence very persuasive.  It also coincides with my clinical experience and that of Dr. Jens Moller and his successor Dr. Michael Hanson in Denmark.  Its true that a lot of the evidence implicating vasectomy in these conditions is from animal studies, but a lot of it is from experiments with monkeys, which are generally considered as the closest one can get to the human condition.

Over twenty years ago it was shown that baboons  given a high fat diet, and inoculated with antibody producing proteins, developed more arterial disease.   A few years after that the American Queen of research in this field, Dr. Nancy Alexander, and her colleague Dr. Clarkson, showed that diet‑induced arterial disease developed more in vasectomised cynomolgus monkeys than in sham‑operated controls.  They therefore suggested that "The immunological response to sperm antigens that often accompanies vasectomy may exacerbate atherosclerosis", this being the form of arterial degeneration underlying most coronary heart disease.

They followed up this early work with longer term studies which showed even more marked changes.  This was largely confirmed in studies on primates by several other groups of researchers, particularly where the monkeys were overfed and underexercised.

Though the link in monkeys between vasectomy and arterial disease is very clearly established, that in humans is much less so.  Some studies such as the Framingham study of heart disease risk factors in America, found an association while others such as the Oxford Record Linkage Study did not.  The debate continues and the case has yet to be proved either way.

As well as the antibody related theories, there are a variety of reasons why vasectomy might contribute to circulatory problems.  Anything which reduces the production of testosterone or antagonises its actions is likely to contribute to these conditions, for all the reasons which Dr. Moller lists in his book entitled "Testosterone treatment of circulatory diseases".

Mainly this is because of imbalance between the body's anabolic building‑up, restorative, energy producing activities, activities and its catabolic, breaking‑down, energy consuming activities.  As a result, the blood pressure and fat levels rise,  blood clots happen more easily, flow of blood in the small blood vessel becomes sluggish, and the cells throughout the body become less efficient at taking up oxygen and using it.  Consequently the natural rate of wear and tear on the heart and arteries escalates, and this leads to their premature ageing.

The most dramatic case I saw where vasectomy seemed to be directly linked with circulatory problems was James, a young milkman from South London:

" I was fine till I was 21, and then I got the mumps.  It was so bad that my testicles swelled to the size of grapefruit, and I had to borrow a bra from my mum to carry them and ease the pain when I stood up.  They seemed to settle down all right after an uncomfortable couple of weeks, but there must have been some damage because my wife had difficulty conceiving with her first child, and the clinic said my sperm count was low.

We made up for lost time though after that, and after the first ,we had two more quickly, so I thought it was time to have a vasectomy.  There was  a little counselling beforehand, but no medical checks. as I looked and felt completely fit, and was only 34.  No one asked me about the mumps, so I didn' t think it could be relevant.  The operation went fine, and within a week I was back to my old sexy self, or even better.

Ten months later though I didn't feel nearly so good.  I found that on my milk rounds, especially on cold winter mornings, I started getting really bad cramps in first my right calf and then my left.  I was hobbling up the garden paths like an old man, and my rounds started taking longer and longer.  I told my GP about this and he said these symptoms sounded like not enough blood was getting to the leg muscles, but he had never seen this in anyone so young before.

The surgeon he sent me to was also very puzzled, and said surgery was needed, but I didn't fancy it and tried to treat myself by stopping smoking, and exercising in a gym.  This helped for a bit, but within a year I had to give in and have some of the furring‑up in the main artery in the right leg taken out.

This only helped for a couple of months, and then I was back in hospital  having a whole series of complicated plumbing operations, trying to bypass the blockages with plastic tubes.  None of these operations lasted more than a month or two, and I couldn't do my rounds even when I was out of hospital because of the leg cramps.  It got to the point of getting cramp in my right leg at night in bed, and the surgeons started talking about amputation.

I was desperate and would rather have committed suicide than live life as a legless cripple.  Still, I'm a philosophical sort of man who meditates, and I still believed something would happen to save my legs.  well, was lying in a bed on the surgical ward one morning going through the Sunday Times and there was this article about  a Dr. Moller in Copenhagen who was treating cases like mine with testosterone injections.  Fate seemed too have been very kind to me , because a British doctor who was mentioned in the same article and seemed to believe in the treatment was working in the hospital just across the road from where I was.

He and my surgeon got together and agreed it was worth a try.  After all, what had I got to lose, apart from my legs?  Dr. Carruthers really had to fight for the injections. Though my surgeon had given his permission, the hospital pharmacist said he thought the dose suggested was far too high and  among other dire warnings, thought it might suppress my sperm production, which showed how little he knew about my case.  This made the junior doctor who was told to give the injections, as no‑one else would, so nervous that he spilt half the dose out of the syringe each time.

Even so, it  really was amazing.  A few days after I started on the twice a week injections, my legs seemed to come alive again.  The calf pain started taking longer and longer to come on, and I was able to leave the ward and take up my  milk rounds, which badly needed my attention.

One improvement I hadn't expected was that my erections returned nearly to normal after being very lame affairs for a couple of years, and I was only slightly tired for a couple of days after sex rather than being shattered for a week.

Apart from a setback a couple of months later when the old plastic piping the surgeons had left in my right leg got infected and had to be taken out. This briefly made the blood flow in my right foot  very bad indeed so that gangrene nearly set in, but despite this setback things went very well on the injections which my family doctor arranged for me to have twice a week.  I gave up going to the hospital who seemed to lose interest in me when I didn't need any more surgery, and I wasn't sorry to stay out of their hands.

Its now six years since I started the testosterone treatment ,  and  I work out in a gym for an hour most days, swim twice a week, enjoy a great sex life, and having given up the stressful job of being a milkman, I am much happier teaching Tai Chi.

The funny thing is though, none of the surgeons I used to consult seemed interested in why  things went wrong so soon after the vasectomy or why I'm not in a wheel chair now, six years after they said amputation was then only option left ."

More typical of the cases I see where vasectomy appears to have played an important part in bringing on early heart disease is Ken, a motor dealer in his fifties;

"Ten years ago, as we had two kid’s and didn’t want any more, my wife and I talked it over, and we decided that vasectomy was the best option. There was a brief counselling session with the clinic nurse limited to a discussion of its irreversibility , but no medical questions or examination, and then straight in to have the operation. The operation proved difficult and took an hours fiddling about down below rather than the twenty minutes I’d been told.  It was also more painful than I’d expected, both during and for two days afterwards.  It was also quite a lot of bruising in my scrotum, which swelled up and went all colours of the rainbow for weeks afterwards - not a pretty sight!

After twenty-six years of reasonably happy marriage, my wife seemed to go off me following the vasectomy, and we split up two years later.  Fortunately, I soon met another woman and we married immediately the divorce came through.  As I’d had pain in the testicles when I ejaculated right since the operation, though my new wife wanted children, I didn’t fancy trying to have the operation reversed.  Then five years ago, when I was just forty-eight, my libido suddenly dropped, and I started sweating heavily at nights, and early morning erections disappeared.  Then I got depressed, and my wife thought I’d lost interest in her because from being two or three times a week, it was an effort to have sex once a month, and even then it wasn’t a great event.

I went and had a “Well-man” check by our family doctor, who said I was fine, but perhaps I’d been overworking, which wasn’t the case and didn’t really help much.  Then one evening I saw a television programme about the “Male Menopause” and the description seemed to fit me to a T.  When I had a detailed examination, including a PSA blood test and ultrasound scan to exclude prostate cancer, the level of Free Active Testosterone in my blood was found to be low, even though the total level was normal, and there was evidence of an autoimmune reaction following the vasectomy.  This included antisperm antibodies, immune complexes, and some wonderful things that sounded like a woodland bird, but I would rather have been without, called “Speckled FANA’s”.

More important than all this interesting information was the news that the condition could be helped by testosterone treatment.  I was started straight away on testosterone capsules by mouth, and within a month my libido had picked up, and life was more interesting  again for both me and my wife, who had nearly lost hope before that.  I started feeling very fit, and was generally more active, in bed and out, especially when I went on the pellet implants.  I’ve been keeping very well on these for over three years now, and when they begin to run out after six months, my wife says I should think about her, and go back for a “top-up”, which I’m happy to do, especially as I get a full check-up each time to make sure it’s safe.”

If you look at the research studies which have been done on the effects of vasectomy on humans, you find widely conflicting reports.  Most of them unfortunately are relatively short-term, lasting only two to five years, certainly before the complications I see ten to fifteen years later arise.  One of the best conducted and reassuring studies was reported from Oxford in 1992, and found that “Vasectomy was not associated with an increased risk of testicular cancer or the other diseases studied.  With respect to prostate cancer, while we found no cause for concern, longer periods of observation on large numbers of men are required”.

However this study did not cover impaired sexual function and other symptoms of the andropause, and it is difficult when seeing case after case of severe menopausal and circulatory disease problems which appear to be directly associated with vasectomy to be entirely convinced of its safety by the statistics of very artificial population studies.

Also the vasectomised men are likely to be a very atypical self‑selected group of clean living, well informed, health‑conscious men in stable and loving relationships, who might be expected to enjoy better health all round, and yet are being compared with control populations who may lack these benefits.

There are also powerful lobbies both inside and outside the medical profession with vested interests in maintaining the "safe" image of vasectomy.  Firstly, doctors who have been promoting it for many years don't want to change their tune and to have to face the possibility of being in the wrong.  I saw this very clearly in 1979 when alarmed by the similarities between Dr. Mollers experience with his men, and the evidence from the research in monkeys, I encouraged a very well‑informed and level headed medical correspondent for a popular national newspaper to write an article analysing the vasectomy dilemma, and coming to the conclusion that "It's safer to wait".

Having done his homework very thoroughly, to the extent of visiting Dr. Moller's clinic in Copenhagen, he stated in his article "The view I have reached can be summarised as follows: with the present state of knowledge, I wouldn't dream of having a vasectomy myself".  Though his article was carefully researched and cautious by journalistic standards, there was an immediate outcry by the medical establishment.  The British Pregnancy Advisory Service dismissed his report as "scare‑mongering" and other experts he had consulted to get a balanced view before publication asked him not to write about it at all.

I was involved in several radio and television debates on the question at the time, and the main argument of the antagonistic doctors was "Vasectomy operations have been carried out for about a century and there have never been reports of an association between vasectomy and atherosclerosis in man".

Would they have dismissed such evidence of arterial damage in monkeys, the experimental animal generally considered closest to man, if it had been produced by a drug rather than an operation?  It is more likely there would have been a public outcry, and the drug would have been taken off the market pending further research.

All this fierce opposition to even a pause for thought on the vasectomy issue was before the questions of any possibility of it affecting liability to testicular or prostatic cancer, or contributing to the hormonal disturbances involved in the male menopause, had been raised.  This reluctance of the medical profession to discuss issues it does not wish to think about is likely to be even greater when the financial considerations of the vasectomy industry are taken into account.

In America for example, it is estimated that 500,000 vasectomies are being carried out each year.  Assuming on average, with operative fees and all the associated costs such as testing for absence of sperm three months after the operation, the cost of each vasectomy is $400, that is an annual turnover of two hundred million dollars.  Add in another fifteen million dollars for the 1% of men who want the operation reversed at $3,000 dollars each, and a similar amount for treating the other short‑term complications such as infection, pain, cysts, granulomas and so on, and this is quite a big business, well worth protecting.

There is however one consideration which might give American doctors in particular cause for thought before they continue to recommend and perform vasectomies.   This is that just as the drug companies are having to defend some very large‑scale group actions for everything from breast implants to drugs such as Thalidomide and Norplant.  If convincing evidence was produced that serious damage might result from either the antibody formation or hormonal changes which many studies have already shown to occur after the operation, this would open the floodgates for a torrent of highly emotive litigation cases.

Having enquired in my male menopause clinic for details about their vasectomy in over 200 cases, from not just Britain and Ireland but America and Canada as well,  there is usually very brief counselling by non‑medical staff, limited to the issue that the procedure must be considered irreversible, and seldom if ever any medical or psychological checks. No enquiries are made about previous histories of mumps or the other infections already mentioned as damaging the testes, or of relevant family histories of heart disease, high blood pressure or diabetes.

The brochure selling vasectomy in one large clinic in London contains much less information than would be allowed for any medicine which was prescribed for patients.  The details are very brief and so incomplete and inaccurate as to flout advertising standards, let alone medical guidelines for informed consent to treatment.

There are four brief paragraphs on possible hazards of the operation, which I quote in their entirety so that you can form your own impression whether this is a full and fair advice in view of what was send earlier:

"Complications, although very rare, can occur with any surgical procedure, however minor, and if you are worried about anything please feel free to call us for advice, or alternatively, if it is convenient, your own GP."

"There is no evidence of any long‑term risk to men's health after vasectomy, in fact many couples find greater enjoyment once the risk of unwanted pregnancy has been removed.  Orgasm and ejaculation are not affected.”

”Sperm continues to be produced by the testicles but its passage to the penis is blocked, so it is reabsorbed by the body, just as the body continually re‑absorbs all unused cells.” 

“Vasectomy has absolutely no effect on the production of male hormones, the only difference is purely mechanical in that the semen no longer contains sperm".

Continuing with this limited "purely mechanical" view, the form the patient completes before the operation usually has more room for payment details than medical details. 

Often immediately after signing this form the young man, who may be only in his twenties or thirties, without even the time to reconsider which he would have if he were buying a washing machine, is led off to have an operation with possible life‑long complications of which he knows little, performed by a doctor of whom he knows less. Lawyers defending such cases in the future may have a hard time proving that the individual or organisations performing vasectomies under these conditions were acting responsibly towards their patients.

Governments also see vasectomy as the cheap and simple answer to population control, and don't want to hear any bad news about it.  This was seen in March 1991 when Lord Anthony Blyth in the House of Lords asked Her Majesty’s Government "Whether they will take steps to discourage the vasectomy operation in view of the possible harmful effects in the long term.”

The Minister, answering on behalf of the Government, Lord Henley, immediately said “No, my Lords.  The decision as to whether or not a vasectomy should be performed in any particular case is one for the patient and doctor concerned, taking full account of all the clinical issues involved.  The patient is entitled to have sufficient information on which to make a balanced judgement.  It is for the doctor, as part of the counselling process, to decide what risks, if any, the patient should be warned of and the terms in which any warning should be given.” (My italics).

Under further questioning the Minister confirmed that the Government were satisfied that men were indeed being given adequate advice, discounted the studies associating vasectomy with testicular or prostatic cancer, and omitted to mention any of the studies relating to circulatory disease.  Another Lord was of the opinion that “If there was any evidence of harmful effects from this comparatively minor operation, whether in the short or long-term, should not the chief medical officer of the department inform general practitioners of  that fact?  As he has not taken that step, am I entitled to assume that there are no such dangers?”.  The Minister confirmed he was.

I entirely agree with critics who say that the evidence against vasectomy is not conclusive yet, and much more research is needed.  However, as elsewhere in this book, discussion of the topic has deliberately been made provocative to stimulate research and informed debate. Those who have had vasectomies should not be unduly alarmed because most of the long‑term complications described are likely to be infrequent, and andropausal symptoms generally respond very well to testosterone treatment.

However, sometimes higher doses seem needed in this situation, and because the condition is not reversible, treatment may need to be prolonged.  Also, unless it is needed to restore fertility, the chances of success decreasing with time, reversal of the vasectomy is not recommended, and might even stir up a fresh storm of antibody production.  It is also quite an expensive operation, and there are only a few surgeons who have the expertise needed for this delicate form of microsurgery, which even in the most experienced hands has its own range of post‑operative complications.

The first recorded vasectomy was by a British surgeon, Sir Astley Cooper who 1823 vasectomised his dog.  My clinical experience over the past fifteen years has completely turned me against the operation and made me firmly of the opinion that it shouldn't even happen to a dog.  If you or a friend are thinking of having the knot of vasectomy tied, my earnest advice to you would be the same as Mr Punch's to those about to tie the knot of marriage ‑ Don't!

Having answered at least some of the questions about how the Male Menopause or Andropause happens, and the part which vasectomy may play, it's time to find out the good news, that it can usually be safely and effectively treated by giving testosterone.